Radiation Therapy Oncology Group (RTOG) Semi Annual Meeting
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Radiation Therapy Oncology Group (RTOG) Semi Annual Meeting Cancer Disparities Research Partnership Programs (CDRP) January 18, 2008. The Evolution of a Novel Radiation Oncology Cancer Disparities Research Program in an Indigent Los Angeles Community.

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Radiation Therapy Oncology Group (RTOG) Semi Annual Meeting Cancer Disparities Research Partnership Programs (CDRP)January 18, 2008

The Evolution of a Novel Radiation Oncology Cancer Disparities Research Program in an Indigent Los Angeles Community

Urban Latino African American Cancer (ULAAC) Disparities Project

Michael L. Steinberg, MD, FACR, FASTRO

Principal Investigator

David C. Khan, MD

Co-Principal Investigator

Nicole C. Harada, CCRC, CCRP

Research Coordinator/Data Manager


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Project Updates

  • Navigator Training Program

  • Patient Data

  • Barriers to Care

  • Clinical Trials

  • Telesynergy

  • Quality Assurance

  • Instability of Health Care Delivery in South LA

  • Publications

  • Media Coverage


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Patient Navigator Training Program

  • The 9-hour navigator training course emphasizes:

    • Investigating and implementing resources for patients in a timely fashion

    • Listening compassionately and non-judgmentally

    • Completing appropriate records of all interactions on behalf of the patient

    • Empowering patients to self-advocate in the healthcare realm


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Training Program Improvements

  • Prospective navigators are interviewed rather than oriented(effective 9-05)

  • Increased focus on clinical trial benefits and patient protection (effective 1-06)

  • Increased training time from 6 to 9 hours (effective 9-06)

  • Added patient/navigator dialogues (effective 9-06)

  • Added charting exercises (effective 9-06)


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Navigator Support

  • More clinical trials in-services

  • In-services on related health topics

  • In-services on available resources

  • Checking in by phone or note with “absentee navigators”

  • One-to-one recordkeeping support

  • Greater physician presence at meetings

  • Four-page monthly newsletter starting June, 2007

  • Field trips every two months starting July, 2007

  • Birthday recognition

  • ACS teleconferences


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Navigation Process

  • Overseeing and addressing immediate barriers to care (June 2005)

  • Formalizing the process of offering navigation to patients (June 2006)

  • Increasing navigators’ presence in Radiation Oncology (August 2006)

  • Defining in-house navigator role (October 2006)

  • ULAAC move adjacent to Radiation Oncology (April 2007)

  • Including navigator input when clinical trials are offered (June 2007)


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Training Program

  • 22 active navigators

    • 18 Women

    • 4 Men

    • 11 cancer survivors


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Patient Data

Patients accepted navigation by gender:

208 Males 207 Females

64%

36%



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Most Common Reported Barriers to Care of Patients Approached


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Measuring the Effectiveness of Barrier Solution Identification

  • Patient-specific barriers to care are identified during the patient intake conducted by a navigator

  • Records are maintained and audited to determine number of days to barrier solution identification

  • Barrier solution includes assigning a navigator (psychosocial barriers) and identifying community resources (functional barriers)


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Mean Number of Days to Barrier Solution Identification from IdentificationApril 2005 – November 2007


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Trials Open for Accrual Identification





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ULAAC Health Services/Quality Instruments Identification

  • Patient Satisfaction Survey

    • Administered monthly via telephone

  • Quality Assurance Patient Evaluation Survey

    • Administered monthly via telephone

  • Cancer Post-Treatment Survey

    • Administered at first follow up visit



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Patient Pretreatment Condition Identification

  • No statistically significant differences detected in measured baseline conditions between those who opted for / against navigation (n = 197).

  • No statistically significant differences detected in patient Education, Income, Marital Status.


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Cancer Post-Treatment Survey Identification

During my cancer treatment…

  • 4 point Likert scale: 0 = Never… 3 = Always

  • No statistically significant differences between patient’s navigated / not navigated detected in retrospective self-report of cancer treatment phase.


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FACIT-G – F Identificationunctional Assessment of Chronic Illness Therapy (General)

  • Patients opting for no navigation faired better than those who were navigated on 5 of 8 metrics (*p< .05).

  • Findings may be attributable to preexisting differences in social support systems, sense of personal independence, emotional robustness, prognosis, treatment methods, etc.

  • Corresponding qualitative investigation in progress to explore this issue in depth.


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Patient’s Evaluation of Navigator Identification

  • Likert scale: 1 = Strongly Disagree… 5 = Strongly Agree

  • No statistically significant differences detected in patient satisfaction scores regardless of navigator’s cancer history.



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Focus Groups Conducted by IdentificationRAND Corporation by Project Year


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RAND Patient Care Survey Identification

Purpose

  • To assess patient experience with and elicit feedback about the Patient Navigator Program

  • The information collected will be used to document aspects of the program and lessons learned to be able to share with other sites interested in having a Patient Navigator Program as well as to inform the current program

  • The target number of 40 patients (both navigated and non-navigated)

  • Feedback will be presented to program at the end of data collection and analysis


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RAND Patient Care Survey Identification

Methods

  • Telephone survey

  • Administered to patients who had a navigator and those that chose not to have a navigator

  • Administered mid- and post-treatment

    Instrument

  • Semi-structured

  • Domains include:

    • Barriers

    • Self-Efficacy

    • Patient Satisfaction

    • Quality of Interaction

    • Demographics


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Continuous Quality Improvement Process Identification

  • Deming and Juran

    • Quality Enhancement in Operations

  • “Lean Thinking” Process to Improve Navigation

    • value as defined by patient

    • value stream care mapping processes

    • one piece flow

  • Care Process Mapping


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“Lean Thinking” to Improve Navigation Identification

  • Current State

  • Future State Value Stream

  • Standardization

  • Elimination of inefficiencies

  • Decreases number of steps for delivering services

  • Ultimately improves quality and efficiency


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Pre-Consultation Intake Identification

Patient Referral

(Phone call from patient or referring physician)

Appointment Made

Information Gathered (demographics)

Patient Records Requested

Financial/

Insurance Authorization

Day of Consultation

(Patient arrives one-hour early to complete billing/medical paperwork)

In House Navigator intake & assessment of barriers

In House Navigator discusses clinical trials

Physician completes consultation

Oncology Nurse

Physician

(H & P)

If eligible for clinical trial,

If not eligible for clinical trial,

Immediate barriers addressed

In House Navigator introduces, discusses, and offers navigation to patient

Accept

Decline

Undecided

Radiation Oncology notifies ULAAC if barriers arise

ULAAC follows up with patient


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Initiation of navigation process Identification

Navigator Coordinator assigns/matches navigator to patient (taking into consideration preferences & skills)

Navigator Coordinator notifies navigator of assignment (mails intake form)

SOAP form documentation process initiated at initial call to pt

Navigator contacts patient

Navigator reports to ULAAC

SOAP

Audit

Navigator & patient arrange face-to-face meeting when possible

Welcome letter (including program brochure, and educational materials)


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Ongoing Evaluation & Assessment of Patient Barriers (ULAAC) Identification

Post treatment monthly follow up PRN

Structured Interview

Coordinates with clinical staff

Navigator contacts patient 1-5 times per week during treatment

Comfort Calls

Navigator Meetings

SOAP Forms

PSS

QASI

CPTS

Addressing Barriers

CTQ

RN/MD QA

Ongoing Lay Navigation

  • Barriers recorded in database:

    • Date

    • Resources identified

    • Date resolved

    • Resolution resource

Navigator identifies difficult barriers & coordinates with ULAAC

Professional staff assess barriers

Barriers are addressed by immediate referral

Barriers

Audit


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Instability of Health Care Delivery Identificationin the South Central Los Angeles Area


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CFHS Service Area Identification


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Instability of Health Care Delivery Identification

  • 1995 - Tenet Health Systems purchases Centinela Medical Center

  • 1996 - Centinela Community Foundation formed - $55,000,000.00

  • 1997- The money leaves the community, becomes part of California Foundations


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Instability of Health Care Delivery Identification

  • 2001 – Daniel Freeman Memorial charts 11th straight year in the red; Tenet comes to the rescue to purchase the financially distressed hospital

  • 2002 – Tenet melt down…no capital expenditures for Centinela or Memorial campuses

  • 2004 – Tenet divests Centinela and Memorial campuses

  • 11/2004 – Robert F. Kennedy hospital closed


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Instability of Health Care Delivery Identification

  • December 19, 2006 – CFHS abruptly closes Daniel Freeman Memorial campus (except Rad-Onc, ULAAC, Rehab Svcs)

  • From 12/2005 – 10/2007 – CFHS promises to move Radiation Oncology and ULAAC Departments to Centinela campus…not forthcoming

  • 11/2007 – Centinela campus sold site unseen to Prime Health Systems

  • Prime Health Systems cancels Radiation Oncology Center Venture



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Kaiser Foundation –West L.A. Identification

Brotman Medical Center

California Hospital Medical Center

Daniel Freeman Marina Hospital

Daniel Freeman Memorial Hospital

Centinela Regional Medical Center

Robert F. Kennedy Hospital

King Drew Medical Center/MLK

Memorial Hospital of Gardena


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Down But Not Out Identification

  • Developing a free standing state-of-the-art Radiation Oncology Center in the community (12-18 months)

  • Continuing to provide radiation treatment to patients by transferring to nearby treatment center

  • Transferring administrative responsibility of ULAAC grant to Partners in Care Foundation

  • Maintaining radiation oncology services for the community by opening a satellite office for consultation, follow up care, and treatment planning



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Partners In Care Foundation Identification(Partners)

  • Partners, charitable, non-profit

  • serves as a catalyst for shaping a new vision of health care by partnering with organizations, families and community leadersin the work of changing healthcare systems, changing communities and changing lives.

  • Partners nationally recognized leader promoting innovative community and home approaches in geriatric care management, health promotion, chronic disease management, end of life care, addressing ethnic health disparities and introducing positive practice change.

  • Partners has an extensive history in testing, adapting and disseminating evidence-based models.


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Community Partners Identification

Colleges and Universities

Antelope Valley College, Boston University, California State University, Long Beach, California State University, Los Angeles, California State University, Northridge, Mount St. Mary’s College, Occidental College, University of California, Los Angeles, University of Southern California

Hospitals and Healthcare Systems

Antelope Valley Hospital, AltaMed, Catholic Healthcare West, Cedars Sinai Medical Center, Children’s Hospital - Los Angeles, City of Hope National Medical Center, Henry Mayo Newhall Memorial Hospital, Huntington Memorial Hospital, Kaiser Permanente Memorial Care Medical Centers, Mission Community Hospital, Northridge Hospital Medical Center, Presbyterian Intercommunity Hospital, Providence Health System, SCAN Health Plan, St. Mary’s Medical Center Long Beach, Veteran’s Administration of Greater Los Angeles Healthcare System

Social Service Providers

Alzheimer’s Association, Healthcare Partners, Inglewood Senior Service Center, Jewish Family Service of Los Angeles, Joslyn Adult Center, Los Angeles Caregiver Resource Center, Meeting Each Need with Dignity (MEND Clinic), One Generation, Senior Care Network, St. Barnabas Multipurpose Senior Center

Public Organizations

U.S. Administration on Aging, California Department of Aging, City and County of Los Angeles – Area Agencies on Aging, City of Los Angeles Department of Aging, Los Angeles County – Public Health, Los Angeles County – Health and Human Services


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Publications Identification

  • Inequities in Care: Explanations & Solutions for Disparities, Seminars in Radiation Oncology, July, 2008

  • Lay Patient Navigator Program Implementation For Equal Access To Cancer Care And Clinical Trials: Essential Steps And Initial Challenges Cancer, Volume 107, Issue 11 , Pages 2669 – 2677

  • Preliminary Results and Evaluation of MammoSite® Balloon Brachytherapy for Partial Breast Irradiation for Pure Ductal Carcinoma in Situ: A Phase II Clinical Study, The American Journal of Surgery, 192, p 427-33, 2006


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Abstracts Identification

  • Evolution of A Novel Radiation Oncology Cancer Disparities Research Program in an Indigent Los Angeles Community, International Journal of Radiation Oncology Biology Physics, 2007

  • Patient Navigators Tailor Interventions in Minority, Low-Income Populations, National Cancer Institute, NCI Cancer Bulletin, Volume 4, Issue 29, 2007

  • The Use of Lay Patient Navigators to Improve Quality of Care and Accrual to Clinical Trials for Radiation Oncology Patients Who Are Minorities or of Low Socioeconomic Status, International Journal of Radiation Oncology Biology Physics, Volume 66, Issue 3, p S70, 2006

  • Using Telesynergy ® To Improve Access to Clinical Trials at an Underserved Community Based Hospital, International Journal of Radiation Oncology Biology Physics, 2007

  • Patient-Centered Satisfaction and Well Being Assessment in a Lay Patient Navigator Program for Underserved Populations, International Journal of Radiation Oncology Biology Physics, 2007


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Presentations Identification

  • Experiences of an Urban Cancer Care Disparity Program: A Broadly Applicable Model for Quality of Care Enhancement ASTRO, Los Angeles, Ca., October 30th, 2007

  • Disparities in Healthcare: Medical Science Meets Socioeconomics, Politics, Race, Public Policy, and Poverty, Mid Winter Oncology Meeting, Los Angeles, Ca., Jan. 21, 2007

  • The Use of Lay Patient Navigators to Improve Quality of Care and Accrual to Clinical Trials for Radiation Oncology Patients Who Are Minorities or of Low Socioeconomic Status, ASTRO 2006,  Philadelphia, PA, Nov. 5-9, 2006

  • Do Navigators Make a Difference in Acceptance of Clinical Trials?, ASTRO 2006, Philadelphia, PA, Nov. 5-9, 2006


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Presentations Identification

  • Preliminary results and evaluation of MammoSite® Balloon Brachytherapy for Partial Breast Irradiation for Pure Ductal Carcinoma In Situ: A Phase II Clinical Study, American Society of Breast Surgeons meeting, April 2006

  • Development of Lay Navigation Program in an Underserved Community, National Leadership Summit on Eliminating Racial Disparities in Health,January 9-11, 2006 Washington, D.C.

  • Prophylactic Post-Operative Antibiotics for Prostate Brachytherapy, Prostate Cancer Symposium, ASCO, San Francisco, Ca.,2006


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Poster Presentations Identification

  • Patient-Centered Satisfaction Measures in A Lay Patient Navigator Program for Underserved Populations in Oncology, accepted for oral presentation, Western Regional Meeting, February 2008

  • Using Telesynergy to Improve Access to Clinical Trials at an Underserved Community Based Hospital, ASTRO, October 2007

  • Evolution of a Novel Radiation Oncology Cancer Disparities Research Program in an Indigent Los Angeles Community, ASTRO, October 2007

  • Patient-Centered Satisfaction and Well Being Assessment in a Lay Patient Navigator Program for Underserved Populations, ASTRO,October 2007


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Poster Presentations Identification

  • Lean Thinking Process to Improving Navigation, Cancer Health Disparities Summit, July 16-18, 2007

  • Lay patient navigator program for equal access to cancer care and clinical trials, ASTRO Health Services/Outcomes Research In Radiation Oncology, San Diego, CA September 15, 2006

  • A Lay Patient Navigator Program as Part of a Clinical Trials Infrastructure in a Community Hospital Serving Minority and Low Income Patients,Poster Presentation at the Cancer Health Disparities Summit 2006, Bethesda, MD, July 17-19, 2006


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Pending Articles Identification

  • Lay Patient Navigator Training Manual

  • Efficacy of Navigation for the Indigent Cancer Patient

  • Barriers to Care in Oncology: The efficacy of  Lay Patient Navigators”

  • Findings From the ULAAC Disparity Project: Navigator and Patient Characteristics

  • Emerging Approaches for Identifying and Targeting Disparities: Utilization of Quality of Care Evaluation Metrics


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Recent Coverage Identification

Uprising Radio Broadcast, December 12, 2007

“Another Inglewood Hospital Threatened”

Ivanhoe Broadcast news, December 11, 2007

TV story on Patient Navigators (to air in March 2008)

Past Coverage

La Opinion article,

November 11, 2005

“To Navigate Services in a Health System: The Patient Navigator Program Helps Sort Through Obstacles that Make It Difficult to Treat Cancer”

Inglewood Today article, October 12, 2005

“Taking Care of Business: The Urban Latino African American Cancer (ULAAC) Disparities Project”

KCAL 9 news station (CBS) – December 7, 2005 2:00 PM, 3:00 PM, and 4:00 PM news

“ULAAC: New Cancer Program Helps Patients Navigate System”

http://cbs2.com/video/?id=11126Akcbs.dayport.com

On Target

“Documentary 2005”

Media Coverage


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Definition of Success Identification: going from failure to failure without significant loss of enthusiasm


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Contact us: Identification

ULAAC Disparities Project

Centinela Freeman Regional Medical Center,

Memorial Campus

333 North Prairie Ave., Inglewood, CA 90301Telephone: (310) 674-7050, x 4661

Fax: (310) 419-8329

Email: mls@cccma.com

Web: www.centinelafreeman.com

Principal Investigator: Michael L. Steinberg, MD, FACR, FASTRO

Project Administrator: Keith Andre, MA

Keith.Andre@centinelafreeman.com